Wednesday, January 18, 2012

“What percentage of psychiatrists do you think are incompetent?” I asked in a reader poll that ran some six weeks during December and January. Framing my question negatively carries the strong risk of encouraging rotten tomatoes responses and thus undermining the credibility of any findings, but my attempts at positive construction came out totally pathetic. Sometimes negative is the best option.

Eight-nine readers responded to the poll. The poll makes no claim to scientific validity, but I know you’re sure as hell interested in the answers ...

The major finding: 32 percent of you - nearly one in three - thought that more than two-thirds of psychiatrists were incompetent. One in five of you (19 percent) pegged psychiatric incompetence in the 51 percent- 66 percent range (more than half, up to two-thirds).

So - more than half of you think that more than half of psychiatrists are incompetent.

Over on the other end of the scale, just one in four of you (25 percent) thought that a third or less of psychiatrists were incompetent. Only one third of this twenty-five percent (less than one in ten overall) regarded ten percent or less of psychiatrists in the incompetent range. One in five overall (19 percent) responded in the one-third or more to one-half incompetence range.

Okay, how much incompetence in the field are we willing to tolerate? One-third? How comfortable would you feel about boarding a flight if you thought one-third of the pilots were incompetent? How about another branch of medicine, say brain surgery? Nope - doesn’t cut it. Neither does 10 percent, nor, for that matter, does one percent.

So here is what I hear you saying: Three-quarters of you (75 percent) are telling me that you think that a full one-third or more of the people we entrust our lives to have no business practicing psychiatry. More than nine in ten of you (92 percent) are telling me that you think at least one in ten psychiatrists is incompetent.

Mind you, this poll is about your perceptions rather than reality, but your perceptions are what’s important. And if your views are even the slightest bit representative of a wider patient-family member population, then - truly - interventions of biblical dimensions are called for.

Before we get carried away, the practice of psychiatry hardly lends itself to objective judging criteria. In my own field of journalism, a 2010 Gallup Poll reports that only 25 percent of the American public has confidence in newspapers and only 22 percent in television news. (I’m not sure which is the more frightening interpretation - that so many have lost confidence in my profession or that an uncomfortably high percentage of the public actually believes the crap they come across in the media.)

Thus, to be fair to psychiatry, any discipline that operates in the subjective realm is bound to draw a lot of heat, justified or not.

But there is another factor involved: Most incompetent people do not know they are incompetent. A 2000 NY Times article cites research in support of the proposition that the incompetent lack the skills to monitor and evaluate their own performance, thereby perpetuating their clueless behavior.

Research shows that the vast majority of people rate themselves as “above average” across a broad band of abilities. In one study that tested subjects for grammar, for instance, those who had scored around the bottom guessed that they had scored well above the mean. Conversely, the highly skilled are likely to underestimate their competence.

In the words of Thomas Jefferson: "He who knows best knows how little he knows."

I think this represents our dissatisfaction with our psychiatrists more than true incompetence.

Here is how I would answer the question:

I've had experience with roughly 10 psychiatrists. 1 was part of the Yale Psych hospital which I believe to be an evil place and in which it would be nearly impossible, because of the limitations of the institution to do a good job as a doctor. He was, however, terrible.

Of the rest, I'd say about or 4 seemed pretty bad - one quite bad. Now, if we look at this and give me and the docs equal benefit of the doubt, then I would say two were bad. So, out of 10, 3 were bad. This is still not great and even the psychs I've liked I haven't loved but, I think it has a lot to do with the way the psychiatric profession limits them and shapes their hands-on practice.

So, 3 out of ten bad. It's bad, but I think it's the inverse of what the poll found.

Hey, Anonymous. You are absolute correct. The poll is a measure of our dissatisfaction. Your 3 out of ten is perfectly consistent with the poll findings. Other responders may have made higher estimates, but your estimate is a damning one, and your in the overall majority if we use 3 in 10 as the cut-off for a damning estimate.

Hey, Smitty. I'm very glad you brought this up. There is absolutely no feedback loop in psychiatry. Who is going to tell a practicing psychiatrist he or she is doing a bad job? How would a pdoc even know if he or she needs to make some course corrections? In almost every other line of work there are reality checks. I can't think of any in psychiatry, other than someone will notice if you don't show up.

Terrific poll and post. I'm so glad you're addressing this issue. Makes me think of Atul Gawande's article in the New Yorker last fall (discussed here on NPR) about why doctors, unlike writers and professional athletes, don't have someone commenting on their work and pushing them to improve. The best psychiatrists I've seen -- and they're a minority -- have been at teaching hospitals, where this is more likely to happen. But such environments also tend to select for the best.

What to do about the rest? Psychiatrists need to be better regulated -- in Wisconsin, serious disciplinary actions against doctors is rare, with some severe consequences (see: http://www.jsonline.com/watchdog/watchdogreports/111767079.html).

I think another answer is educating patients about what they should expect from psychiatrists. A friend recently told me that her psychiatrist plays music and brings animals with him to sessions, doesn't ask her about her symptoms or side effects, and refills her prescriptions for benzodiazepines and Ambien without comment. She had no idea that this was inadequate treatment.

I think a second poll might be interesting if it looks at the reasons people think psychiatrists are incompetent. For me, it has to do with personality and attitude towards patients, as well as the thoroughness (or lack thereof) of their investigation/questioning.

Your doc can tell you that he, or she, graduated in the 3% range. You can see all the accolades, diplomas, certificates upon their walls. Yet what many do not understand is; there is the TOP 3% and the bottom 3% and all those accolades, diplomas, and certificates are all the same regardless of which end they measured.

When all the time you get is 15 minutes, they scribble the entire time you speak, you have to repeat yourself because they didn't hear you from the get go, and they are too eager to up a med or hand a new one as you go out the door... then they aren't truly treating you.

Also, when every live long thing is "illness related" but no 3 can agree on your illness and 2 argue over 1's diagnosis or decide that you really have maybe 2 more illnesses in addition to - that warrants 1-2 more meds... then really.. really... really

Hey, thanks for the blog on not using the term, "antispychiatry." For some reason my Google alert didn't pick that up yet.

I was one who voted for 10% or less incompetent. As I think back, all of my psychiatrists were smart, educated people doing the best they can. However, medical literature and medical education is so corrupted that docs aren't taught the truth anymore. 1boringoldman.com does an excellent job of explaining this. Doctors can only find truth through their own off the clock efforts. Med students and practicing doctors usually have very intense schedules that limit their off the clock reading into the kind of things we've learned.

Plus it's emotionally difficult to read that you've been harming people you wanted to help. Many more people in recovery know the true story on meds because it's a good news story to us, so it's much easier to read and keep reading on our free time. It tells us we can be free again. It takes a lot of digging to come a place of intellectual honesty about deciding what is true. I read about 150 research articles, 15 books, and went to two conferences before I was sure that Whitaker was right.

Docs have strikes against them for that kind of intense and rigorous digging: the number of hours they work and the pain they must go through to see that conclusion.

Hey, Amy. Excellent points. Funny thing - when I was facilitating a DBSA support group, we the facilitators sought out feedback from the other facilitators, especially if confronted with a novel situation. We wanted to be able to handle the next situation better. We also needed the moral support that a coach can give.

So here we were - not professionals but with a very strong feedback loop, one that allowed for even novices to jump in at the deep end and improve exceptionally fast.

Psychiatrists don't have this. Their patients are the only feedback they get, and - guess what - the incompetent pdocs son't listen.

Hey, Corinna. It was your feedback that got me to swear off using "antipsychiatry." (Ah, the feedback thing!) Re "off-the-clock." I used to joke that I went to more psych conferences than psychiatrists, and it was true. Plus I kept current with the research, which they didn't, plus I had constant contact with individuals in the real world, plus my own lived experience. Not only that, I researched outside of specialities - different illnesses, different disciplines, on and on.

Often my best insights come from reading stuff way outside of psychiatry. Like you said, pdocs don't have this luxury.

So yes, by the time I read Whitaker's book, like you I knew he was speaking with a lot more authority than the top people in the field.

Pity. As you say, the pdocs you have encountered are very smart people.

Re the good news/bad news angle: I hadn't thought of it that way. I wish pdocs could do more for us, but I've always felt empowered by the fact that they can't and that it is up to us.